Epidemiology at the state level is shrinking

I’m an epidemiologist and I train epidemiologists so you expect me to think epidemiology is important to public health. Epidemiology describes the pattern of diseases in the community and tries to figure out why some patterns exist and not others. It is used for both applied health research (causes of disease and disease outbreaks), disease control and for administrative purposes (how many hospital beds will we need, for example). When I was in medical school most epidemiology, such as there was, was done by medical doctors or employees of federal, state and local health departments. Starting in the sixties, academic programs in epidemiology started to take off, and now there are many masters and doctoral level training programs in epidemiology. But still not enough epidemiologists to meet the need, apparently. And we aren’t moving forward. We’re sliding backward.

Periodically since 2001 the Council of State and Territorial Epidemiologists (CSTE) (a non-profit organization of state epidemiologists that advises CDC and promotes the interests of epidemiology in state service) does a survey of the states to see what’s happening in the epidemiology workforce and capacity to perform epidemiological functions. The latest results were just reported in CDC’s Morbidity and Mortality Weekly Reports (MMWR) and the present the kind of dismal picture we all could see with our own eyes without a formal survey. Almost everything in public health at the state and local level is deteriorating even as the demands are escalating, sometimes to the breaking level. Here, for example, are two graphs showing what has happened between the last survey in 2006 and this one (2009) and the current state of affairs for various program areas:

The bars on the left are the number of states have substantial to full (>50%) full capcaity in four key program areas are for 2006. The bars on the right are for 2009. Except for research, which went from 9 states to 10 states, the other program areas showed smaller capacity. The survey was done between April to June of this year, concurrent with the first wave of the swine flu pandemic. The sudden demand to count cases, prepare new programs, measure spread, interpret data and all the rest of the things the public and press was clamoring for feel on fewer shoulders than just 3 years ago. As a result, personnel were borrowed from other essential public health functions, which suffered even more.

This graph shows the status of those other functions before they were stripped to handle the pandemic:

What you are looking at here is the percent of state health departments that have substantial to full capacity (>50%, left bar) and minimal capacity (less than 25%) in key public health program areas. While infectious diseases was reasonably (although not fully staffed; the left bars are percentages of states with more than 50% capacity, not all full capacity), many important public health programs had more states that had no to minimal capacity than states that had substantial to full capacity. It’s a dismal picture for routine but important public health functions.

What kind of things are we talking about here?

Here are four big functions where capacity decreased from just three years ago to the start of the pandemic:

Monitor the health status of the community

Diagnose and investigate health problems in the community

evaluate effectiveness and access of health services

Research into health problems

As the pandemic showed us (although any idiot could have seen it), this was an utterly stupid disinvestment. But we did it, and now everyone is hollering about how we haven’t been able to handle swine flu. You get what you pay for.

It’s a lot more than it appears on the surface, too. I’m in an academic environment where we use the latest tools in computational epidemiology and the laboratory sciences. But in state and local health departments they are starved for people and deprived of these same tools. Despite the importance of timely information and early warning, only about half (53%) the states had automated electronic lab reporting and far fewer web-based provider reporting (41%), automated cluster detection software (24%) or routine coding of location for disease or deaths (29%). Even when the tools exist, most require the basic data to be geocoded by location and that still isn’t routine in more than 70% of state health departments.

I’ve been in public health a long time and I’ve seen many changes. We can do things now we couldn’t dream of doing even ten years ago (cluster detection, routine mapping of disease outbreaks, data mining of routine health data, etc.). We can do them, theoretically, that is. The infrastructure, human and otherwise, that would produce the raw data for these sophisticated tools isn’t there and we aren’t providing it. On the contrary we are gutting state and local health.

Some things are just so stupid it takes your breath away. Not that there are enough ventilators for that problem, either.